Lack of Medical Necessity

July 5, 2016

Massachusetts ophthalmologist Martin E. Cutler and his company Martin E. Cutler, M.D., P.C. agreed to pay $55,000 to resolve allegations they violated the False Claims Act by falsely billing Medicare for ophthalmic diagnostic imaging when there was no underlying diagnosis to justify the imaging.  They also allegedly falsely billed Medicare for office visits where a prior claim for the same visit had been denied and the new claim was not supported by Dr. Cutler’s documentation.  The allegations originated in a whistleblower lawsuit filed by Brian Sachs under the qui tam provisions of the False Claims Act.  Mr. Sachs will receive a whistleblower award of $11,000 from the proceeds of the government's recovery.  DOJ (DMA)

June 30, 2016

Florida cardiologist Dr. Asad Qamar and his practice, the Institute of Cardiovascular Excellence (ICE), will pay $2 million plus release any claim to $5.3 million in suspended Medicare funds, to settle charges they violated the False Claims Act by billing for medically unnecessary procedures and paying kickbacks to patients by waiving Medicare copayments irrespective of financial hardship.  By waiving the required copayments, Dr. Qamar and ICE induced patients to agree to unnecessary and invasive procedures and other services.  Dr. Qamar’s and ICE’s illegal conduct made Dr. Qamar the highest paid Medicare cardiologist in the country in 2012 and 2013.  The allegations originated in two whistleblower lawsuits filed by Dr. Robert A. Green and Ms. Holly A. Taylor under the qui tam provisions of the False Claims Act.  They will receive a whistleblower award of roughly $1.3 million from the proceeds of the government's recovery.  DOJ

July 7, 2016

A Bedford-based transportation service provider has agreed to pay more than $700,000 to resolve allegations that it submitted false claims to the state’s Medicaid program (MassHealth) for medically unnecessary wheelchair van rides, Massachusetts announced. It also allegedly submitted claims for services that should have been provided at a lower cost through a MassHealth transportation broker. The AG’s investigation revealed that REM Transportation Services, LLC (REM) submitted the false claims from January 5, 2010 to December 31, 2014. Many of the MassHealth members allegedly receiving the rides were ambulatory and did not use wheelchairs or need assistance, as required under MassHealth regulations. MA

June 13, 2016

Ubert Guillermo Rodriguez, former owner of Florida-based durable medical equipment maker G.R. Services Equipment & Supplies Inc., was sentenced to 37 months in prison and to pay $918,402 in restitution for his role in a multimillion-dollar health care fraud scheme in the greater Tampa, Florida, area.  Rodriguez admitted that from May 2013 through July 2013, his company submitted approximately $2.6 million in fraudulent claims to Medicare seeking reimbursement for durable medical equipment not legitimately prescribed by doctors and not provided to beneficiaries.  DOJ

June 20, 2016

New York announced the arrest of Joseph Wright, 52, of Middletown NY, for allegedly stealing over $5 million dollars from Medicaid. Prosecutors allege that Wright, as owner of a purportedly not-for-profit organization “Assistance By Improv II, Inc.” (ABI), located at 953 Southern Boulevard in the Bronx, lured thousands of low-income New Yorkers to ABI with the promise of affordable housing, arranged to have them subjected to unnecessary medical tests and then filed false claims for reimbursement with the State Medicaid program. Prosecutors alleged in papers filed in court that Wright unlawfully owns and operates ABI as a medical mill that masquerades as a charitable housing organization. Prosecutors allege that Wright ignored ABI’s professed charitable mission and duped potential clients, most of whom were Medicaid recipients, into surrendering their personal health care information and undergoing purported medical screening to qualify for housing. NY

May 31, 2016

Newark, New Jersey-based Saint Michael’s Medical Center Inc. agreed to pay $450,000 to resolve allegations it violated the False Claims Act by falsely billing Medicare and Medicaid for medically unnecessary cardiac procedures.  The allegations originated in a whistleblower lawsuit under the qui tam provisions of the False Claims Act.  DOJ (DNJ)

May 5, 2016

The City of New York agreed to pay $4.3 million to settle charges of violating the False Claims Act through the New York City Fire Department's receipt of reimbursements for claims for emergency ambulance services that did not meet Medicare’s medical necessity requirement.  This matter was brought to the attention of the U.S. Attorney’s Office through a voluntary disclosure by the City.  DOJ (SDNY)

April 18, 2016

Miami physician Henry Lora was sentenced to 108 months in prison for his role in a Medicare fraud scheme that caused approximately $30 million in losses.  Lora was the medical director of Miami-area clinic Merfi Corporation and admitted that in exchange for kickbacks and bribes, he and his co-conspirators wrote prescriptions for home health care and other services for Medicare beneficiaries that were not medically necessary or not provided.  He also admitted falsifying patient records to make it appear as if the beneficiaries qualified for these services.  In March 2014, Merfi owner was sentenced to nine years in prison for conspiracy to commit health care fraud.  DOJ

April 13, 2016

Florida Pain Medicine Associates, Inc. and its owners, Drs. Bart Gatz, Alexis Renta, and Albert Rodriguez, agreed to pay $1.1 million to resolve allegations they violated the False Claims Act by billing Medicare for medically unnecessary nerve conduction studies.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Rosa Gomez, who had worked in Florida Pain Medicine’s billing department.  She will receive a whistleblower award of $242,000 from the proceeds of the government's recovery.  DOJ (SDFL)